February 24, 2014

I'm linking to The Daily Mail's coverage of this story because it's got some nice pictures showing the physical attractiveness of the physician Milton Wolf and his family and in spite of the British paper's inability to write clearly about whether this man is running for the Kansas state senate or the U.S. Senate. (It's the latter, but DM repeatedly writes "Kansas Senate.")

2012 was again a landmark election in terms of physician candidates, with 50 physicians running as challengers or in open seats for federal office at one point during the cycle. The 113th Congress will welcome two new physicians to the House of Representatives.

Twenty physicians are currently serving in the 113th Congress which include three senators, 16 representatives and one delegate. Seven of these members of Congress are graduates of AMPAC’s Candidate Workshop and/or Campaign School.

I know some people are leaning toward assisting Wolf — here's Instapundit — but why empathize with a man who flaunts his lack of empathy? Here's the direction I lean: What is going on with this promotion of doctors in the American political scene? There's something odd and excessive about our respect for them. We must trust and depend on them when we have medical problems, but why are we bent on installing them in political office? Let's think more carefully about the sort of minds that go into medicine and whether we are not overvaluing them as political candidates.

239 comments:

Don't go to the first link - Daily Mail. After a few seconds up pops a "V Alert" telling you that there are viruses on your computer. Not difficult to make go away but you have to think about how to do it for a second. Forewarned is forearmed.

Let's think more carefully about the sort of minds go into medicine and whether we are not overvaluing them as political candidates.

On an absolute basis, we're probably overvaluing the value of doctors as political candidates.

On the other hand, the typical doctor looks really good relative to the typical career politician who is hungry for power and sadly bereft of real-world experience, practical knowledge, and common sense.

Doctors use logic in their everyday lives. They look for the truth in a situation and most of us believe politicians and lawyers, but I repeat myself, look for what they can convince a group of citizens with more sensibility than sense is the truth.

Anyhow, didn't we all love the doctors of M*A*S*H who laughed in the face of death? Wasn't Alan Alda the face of the new sensitive man we all wanted?

Empathy is overrated in politicians. Alas, those of us who want a leader not a new boyfriend are generally out-voted.

I think you're reading more into DDH's point than is there. He didn't ask if we as a society have overvalued lawyers generally. He asked if they are not given unwarrented respect "in politics" or if they are "over-represented in our legislatures."

His response is more to the question(s) you directly posited, namely:

Where do we get this idea that a background in medicine is particularly apt for lawmakers? How many doctors are there in Congress anyway?

plus your comment:

Let's think more carefully about the sort of minds go into medicine and whether we are not overvaluing them as political candidates.

I think it is safe to ask, if we compare the number of doctors in political office versus the number of lawyers, you may answer your own question.

Personally, I think that to be a medical doctor requires a certain amount of practical intelligence and common sense, rather than an ability to finagle, cajole, and distort information as an advocate, the very definition of a lawyer.

Medical education teaches doctors to view the body as a system so that it can be treated for disease and injury. Too much empathy would interfere with treatment, which sometimes requires doctors to ignore the pain they must inflict. The problem with empathy is that doctors need to turn it off to cure the disease or injury and on to treat the patient.

Among medical specialties, radiology interprets x-rays, cat scans, and other images of the body, often without the doctor even meeting the patient. It is ironic that doctors who are bothered by inflicting necessary pain sometimes go into radiology, where they don't even see the living patient. They concentrate on imaging the problem so that it can be cured, not treating the patient.

Supposedly there's a difference between surgeons, who tend to be highly confident and like to have the ball in their hands, and diagnosticians, who tend to be more reserved, skeptical and less decisive. Something like that.

"Personally, I think that to be a medical doctor requires a certain amount of practical intelligence and common sense, rather than an ability to finagle, cajole, and distort information as an advocate, the very definition of a lawyer."

My point is that we are overvaluing doctors in politics and that our physical need for them distorts our thinking about them and power-seekers are leveraging this distorted thinking.

With any given electoral choice, the voter is challenged to pick the better candidate. I'm not saying lawyers are better than doctors. I'm saying that we need to work on our assessment skills which seem to be off when it comes to doctors.

Wolf displays some particular problems that may tend to exist in the minds of doctors. Choosing a representative, you are choosing a mind to think about policy for you. The mind of the doctor is not as generically good as you might think.

Why not Doctors? At least they are not professional politicians. I'd rather live with a few gaffes. We have Lawyers (and doctors) in congress because they are one of the few occupations that can interrupt their career at minimum cost to run for office. Since medical issues are such a large part of the economy why not have at least 50? Ditto for ex-military, business guys, farmers etc.

The problem with lawyers in politics is that they tend to think that writing a law or regulation is the solution for almost all social problems. Unintended consequences don't figure heavily enough in their thinking.

"...we are overvaluing doctors in politics and that our physical need for them distorts our thinking"

So what? Hell, Minnesota elected an actual comedian.

here's Al on Letterman:"Al Franken: “Right. So they wanted to smear the guy who came back with the report, and so they out his wife and said she sent him there. This is essentially, you know, George H.W. Bush, the President's father, was the head of the CIA and he has said that outing a CIA agent is treason.”

Letterman: “It is treason, yes.”

Franken: “And so basically, what it looks like is going to happen is that Libby and Karl Rove are going to be executed."

Letterman, in mock indignation: “What? What! Really?”

Franken cautioned: “Yeah. And I don't know how I feel about it because I'm basically against the death penalty, but they are going to be executed it looks like."

Historically, physicians have been respected members of society. Their calling is a noble one, and they take a sacred oath to behave ethically. Their appeal could cross partisan lines, because they are seen as acting impartially for the good of all mankind. It's really no surprise that they would be able to win elections.

But just recently, I mean since 2009, government and health care have become one and the same Leviathan organization. Now anyone who cares about his health care must engage in political activity to influence it. Even conservatives, who wish to repeal Obamacare, can see the usefulness of nominating a doctor, who can debate the issue with more authority than a layman.

There are many jerks in medicine. This guy showed terrible judgment. He is probably a jerk.

But I don't see why you would be excessively worried about having a doctor or a nurse represent you. They are trained decision makers in one of the helping professions, have to take responsibility for their decisions, and their work brings them into contact with people from all walks of life. They are working where the rubber meets the road.

Many of America's pathologies can be laid squarely at the feet of our permanent political class in Congress, most of whom serve for decades in gerrymandered districts and won't leave their cozy Washington sinecures unless they do something so egregious that that have to resign. Most of them are lawyers.

I'm of two minds abut this. On the one hand, it would be good to just give the toilet a good flush (or more -- some of them are definitely four-flushers) and get rid of the whole damn lot of them, and bring in a completely new, fresh set of representatives and set term limits on them. Put an end to career politicians who spend decades in Washington, luxuriating in decadence of our imperial capital.

On the other hand, that wouldn't solve the concomitant problem of the rest of the permanent Washington establishment -- the lobbyists and other assorted corrupt hangers-on -- who simply would eat the lunch of the naïve, inexperienced new representatives.

It would be nice to have people who are familiar with the law, but since most of the lawyers currently in Congress don't even read the mammoth tomes they send forward, like Obamacare, it seems that is less than a prerequisite than one would think.

The best thing we could do is ask the British to come back and burn the place to the ground again.

Ann: We not only trust Doctors for their expertise in medicine. Doctors are also some of the most successful entreprenuers in the United States. They are also operators of small businesses. They are keenly aware of the balance of regulation and the marketplace.

Perhaps if we had more doctors in Congress, the Obamacare legislation wouldn't be such a mess. We need more people with real world experiece (doctors, teachers, business owners, etc.) in legislatures. Instead, we get a bunch of dumb ass lawyers who think they know everything about everything. I'm not saying that no lawyers should be in legislatures and Congress, but the percentage should be a lot less than it is now. The percentage of lawyers we have now hardly constitutes representative government.

Office holders representing the American people were to be from all walks of life. Shouldn't the greater outrage be that a very high percentage of all democrats never held an actual job, never created an actual job, and never had to work a day in their life? Oh and these same democrats are now wealthy because of their political/lobbyist connections...and are often for-life career politicians.

"...in spite of the British paper's inability to write clearly about whether this man is running for the Kansas state senate or the U.S. Senate. (It's the latter, but DM repeatedly writes 'Kansas Senate.')"

British writers write differently from American writers. Another candidate for the "overwrought" tag.

Where do we get this idea that a background in medicine is particularly apt for lawmakers?

@Althouse, where do you get the idea that law is an apt background for lawmakers? Is there anything about the current US Code that suggests to you that the law as it stands today is about anything other than increasing the demand for lawyers and making them more wealthy?

And, answering your question, ever since the US government took over our healthcare system it has become critically important to get people into office who understand the realities of healthcare delivery.

"Too much empathy would interfere with treatment, which sometimes requires doctors to ignore the pain they must inflict."--ddh above @ 6:38am

The good professor skips right over this important point because it doesn't fit her goal. Example: Paul Volcker had to choose between higher inflation or continued stagflation and he chose to tighten the money supply and suffer the higher inflation because it was the less dangerous thing even though painful.

Lawyers, trained as we are, who enter politics promise everybody who will listen that there is a free lunch somewhere at the end of the rainbow. Because we're trained to think laws, lawyers, judges and et cetera can be helpful without imposing costs. We talk about sliding scales as if they're not blunt instruments but can be precisely tuned to fit exactly our purposes.

It is a lie.

Althouse's comment is sophomoric because it doesn't admit why Wolf's humor causes her discomfort. Oooh, that comment made me sad so maybe doctors, as a group, should be more critically examined when running for office. Also, ignore all the positive interactions you -- dear readers -- have had with doctors and all the bad ones you've had with lawyers. Don't let that inform your opinion.

My brother is a doctor and I agree that doctors make poor leaders in government. Their views of the world are skewed, in my opinion, and not a in a good way. But their stature as doctors makes them think that they are infallible and it is impossible to have a balanced discussion with them about anything. I hope that Obamacare has been a wake up call for them, but I bet they won't admit it.

My brother is a doctor and I agree that doctors make poor leaders in government. Their views of the world are skewed, in my opinion, and not a in a good way. But their stature as doctors makes them think that they are infallible and it is impossible to have a balanced discussion with them about anything. I hope that Obamacare has been a wake up call for them, but I bet they won't admit it.

Maybe not by non-lawyers, but among themselves they certainly think they are more valuable to society and think themselves more brilliant than they actually are.

I grew up with lawyers. My father was one for almost 50 years, and a lot of his friends were also lawyers and judges. So, no surprise that several in my generation are lawyers too, including, sometimes unfortunately for everyone else, yours truly.

But, I think that a law degree should disqualify you from running for political office, and esp. at the national level. Last I knew, a majority of Congress had law degrees (not calling them all lawyer, because there are always some who get the law degree just to go into politics - e.g. Ted Kennedy), plus apparently the bulk of the lobbyists in DC are legally trained (the only place I know of in the country where lawyers can share fees with non-lawyers). Wonder why the PPACA (ObamaCare) or Dodd-Frank are 2,000+ pages long? Wonder why there are thousands of statutes that you can criminally violate any more? Why pretty much everyone, without a lot of professional help, screws up their tax filing with the IRS? It is all the lawyers. Fewer lawyers in and around the government at the top would probably result in a much more understandable body of law that we have to live under.

Why are lawyers so bad this way? Because this is what they enjoy and do for a living. There is some evidence that the smarter you are, the more you understand and enjoy complexity. And, indeed, the former is maybe one of the best explanations for intelligence. Attorneys, as with physicians and thos with PhDs, have IQs that are, on average, about one standard deviation above the mean (according the "The Bell Curve"). Physicians tend to apply their love and ability with complexity to the human body and dealing with sickness to such. Attorneys, by training, apply it to the spoken and written word, which is why our laws are now so voluminous and complex. You have a small (in terms of all the attorneys in the country) group writing the laws, and then a much larger group advising people how to comply with, or get around the laws that the first group drafted. Great for the lawyers. Not so great for everyone else.

It seems that the Republicans tend to have a physician or two in the Senate, and they tend to be outstanding Senators. Much higher quality, in my view, than the typical lawyer in Congress.

Althouse said:" Let's think more carefully about the sort of minds go into medicine and whether we are not overvaluing them as political candidates."

What a shame. All those doctors are taking valuable political positions which could be filled by lawyers. More seriously, Obamacare has already done so much damage and will do so much in the future that we need some medical care professionals who actually understand medicine to fix the mess.

Milton Wolf is a radiologist. Depending on his subspecialty he may read pictures all day with minimal contact with actual patients. Because radiologists see so many gruesome things on a daily basis they have to develop a psychological barrier to protect them from the recurring tragedy. He may be a sociopath who lacks empathy for other people or he may be someone who has blocked out the reality that there are real people behind those pictures. In any case, considering the privacy laws, it is surprising that he is displaying those pictures.

Medicine is an art, not a science. It is supported by many sciences, but so is ceramics. Medicine evolves by examining and adopting what works.

Law evolves (as far as I can tell) adversarially (sp?), someone sets a limit based on desires and then lawyers try to figure out how to get around it. I know that's an oversimplification, but I'd rather be ruled by what works than desire frustrated.

"Even with the American Medical Association’s endorsement, a large majority of American physicians remain staunchly against Obamacare.They see the program as creating an undue burden on their practices in light of decreased reimbursement, increased bureaucratic oversight, and a complex array of unnecessary and intrusive technological mandates which will further distance them from their patients.

How about we look for leadership skills in somebody? That would be new.

Can we find someone who shows a bit of flair for governing? Someone, maybe, quotable? Who makes good sense? I don't see a lot of those.

Would we consider someone who doesn't care for the limelight? Who just wants to do a good job at something, and doesn't even want your pat on the back, but only to be left alone to do it - would we take that guy?

Are the values of the "helping professions", admirable as they might be, desirable in one who governs? This may also be asked of teachers, social workers, nurses, psychologists, veterinarians and dental assistants.

One might also ask if the single-minded advocacy of lawyers prepares them to represent all the people and fairly govern a nation.

Have we, in fact, a sufficient pool of persons of the talent and disposition to perform the offices of so large and far-reaching a government as we have constructed?

If there is an increase in physicians interested in running for political office, might it not be because politics is increasingly intruding into the practice of medicine? Obamacare is a notable example, but it is not the only one. Prosecution of physicians treating chronic pain is another. There are many examples.

I saw a references in the comments to the "helping professions." In a Venn Diagram, there would be substantial overlap between members of the "helping professions" and what I refer to as the ministering class. I do not want to be governed by people who perceive me more as a social service client than as a citizen.

April Apple said..."Even with the American Medical Association’s endorsement, a large majority of American physicians remain staunchly against Obamacare.

April, there are no numbers in that link, it is just one nutjobs opinion.

As far as I can tell there is no good survey specifically on physicians attitudes but, "the American Medical Association, the American College of Physicians, the American Academy of Family Physicians, the American Academy of Pediatrics, the American Osteopathic Association, the American Psychiatric Association, and the American College of Cardiology all endorsed the ACA. These groups represent hundreds of thousands of physicians across a wide range of medical sub-specialties."

It is pretty clear where the majority of physicians stand based on the stance of their professional organizations. This is particularly striking given that MDs are likely to receive a reduced rate of compensation as health care goes forward and therefore have some vested interest in opposing the legislation.

Get Congress out of medicine and the doctors will get out of Congress.

But shit, being Senator is far easier and more lucrative than grinding out 40-60 patients a day in Family Practice in Squat-n-pee, Utah or Toadbutt, Nebraska, with $150K in student loans and Obamacare set to screw you eight ways to Tuesday.

And for another thing, since congress is limiting the earning potential of doctors, it makes sense for them to gravitate to where the money is. There seems to be no limit to the earning potential of congressmen.

But, I think that a law degree should disqualify you from running for political office, and esp. at the national level.

It is instructive to look at the fate of Steven Chu. He is a Nobel prize winner and a very successful scientific administrator yet his time in politics is viewed very negatively. From a rational viewpoint he did a perfectly fine job but he lacked the lawyers knack for spin and deception which doomed his tenure in the eyes of the media. The natural mendacity of lawyers means that they will almost always outcompete more technically competent people. Margaret Thatcher and Angela Merkel are interesting exceptions, although neither was a first rank scientist.

Physicians are not a monolithic group. Surgery is an altruistic form of sadism. Surgeons surge. They're competitive, decisive, and lots of them are jocks. In another life they'd be brokers.....Internists are pensive, gentle, and empathic. In another life they'd be stock analysts or even English teachers.......When you think of doctors as arrogant pricks, you're probably thinking of a surgeon. When you think of doctors as kindly, decent men, you're probably thinking of an internist.

"A majority of physicians support the ACA, so they have that going for them. On the other hand there is Michael K. It's a tough call."

It nay be an indicator that the White House photo op of "doctors" supporting Obamacare included non-doctors in white coats. Like the girl fourth from the right in the photo.

The doctors who did support Obama are mostly employed on salary and politically leftist.

A few years ago, there was a student group supporting single payer. I was asked to be a faculty adviser to that group because I was perceived as knowing about health policy. I don;t believe that group exists anymore. At least it hasn't met in several years.

I used to tell students that the worst of the reform turmoil would be over by the time they were starting practice. I don't think that is true anymore.

A friend was over for dinner last night. She is an OR supervisor. The hospital is going through another wave of layoffs in spite of the fact that they are insanely busy. They are trying to cut expenses to match the declining revenues. It will get ugly.

A few years ago, I spent some time studying other systems to see how health reform should go. If anyone, like Freder, is interested it is here.

The physician in question is a radiologist. He examines X-rays, not patients. He was making fun of be X-rays and not the patients. There's very little dilettante interest in reading X-rays. I presume the x rays and the jokes were posted for those in the know and not for general consumption. This looks like a manufactured controversy.

No there would be a point. You would fully demonstrate your ability to cherry pick from third rate web sources any dubious information that you can find in order to bolster a weak case. As I noted, MDs will lose financially from the ACA. There would never have been universal support for the ACA. We need medical costs to go down. Only the hopelessly stupid person doesn't recognize this.

That is one reason why I oppose Obamacare. It does not do that. In fact, it combines the worst sort of perverse incentives with forcible rationing. The question will be which side wins. The only way to control costs is to use market forces instead of forcible rationing. If you think rationing would work, please explain why the mandates for employers have been postponed several times.

That's why I supported the French system in 2008 when I wrote those posts. The Canadian system just creates medical tourists like the ones who go to Spokane or Minneapolis for care.

The French system provides basic care for everyone and allows those who wish to pay more to do so.

Hmmm. 92 comments, several of which compare Wolf's open lack of empathy to Obama's ability to fake empathy, and no one mentions that they're second cousins? (The linked story's "distant cousins" is hogwash: I've met lots of my 2nd cousins, and "distant" to me implies 4th or 5th cousins, maybe 3rd, but definitely not 2nd.)

On the whole, I think we can all be glad that Bill Clinton's interest lay in the field of law and politics and not medicine. He would have been particularly problematic as a gynecologist. A physician can be too empathic.

Only lawyers are qualified to lord over us, the little people. That's what "lawyer up" means. Nobody says "doctor up". But one may doctor evidence to score an advantage in court. Can't trust those doctor scums, can we?

Lawyers are uniquely able to churn out thousands of pages of lawyerly speaks that no two persons could agree on the meanings. The bickering parties go to court to see lawyerly priestlings read the entrails, the high priest would determine which party has more claims to the entrails. Ultimately the Supreme High Priests would interpret birds flight patterns to settle the Law for the moment.

...and that our physical need for them distorts our thinking about them and power-seekers are leveraging this distorted thinking.

Who's this "we" you keep talking about? It'd be nice if you gave an actual example of how this alleged psychological attitudes toward doctors is driving voting. Yeah, what else could be driving an uptick in doctors' interest in politics these days? It's a puzzler, it is.

So far your "evidence" for the existence of this distorting deference seems to be the mere fact of X number of doctors in elected office, or merely running for office - and one douchebag radiologist with a facebook page. This "logic" could apply to any group occupying office, with as much merit.

Do people in general respect the profession of medicine more than they respect law or career politics? For the most part, yes, and for good reason. (Though that will change as/if conditions kill the attractiveness of the profession to high-quality entrants.) It's quite a leap from that to the befogging uncritical worship you're positing here.

The only people I can think of who exhibit an "awe of" and mindless "deference toward" doctors are a certain subset of silly people who are prone to "distorting deference" toward other kinds of personal attributes of politicians that have nothing to do with ability to govern wisely, either. Cough, cough. I doubt we're any worse off with them voting for an "M.D.", than we are with them voting based on those other attributes.

"How about we look for leadership skills in somebody? That would be new.

Can we find someone who shows a bit of flair for governing? Someone, maybe, quotable? Who makes good sense? I don't see a lot of those.

Would we consider someone who doesn't care for the limelight? Who just wants to do a good job at something, and doesn't even want your pat on the back, but only to be left alone to do it - would we take that"

dmoelling said... Why not Doctors? At least they are not professional politicians. I'd rather live with a few gaffes. We have Lawyers (and doctors) in congress because they are one of the few occupations that can interrupt their career at minimum cost to run for office. Since medical issues are such a large part of the economy why not have at least 50? Ditto for ex-military, business guys, farmers etc.

Teh thing about diversity: unless it deals with body parts the left is absolutely against it.

A man in a hot air balloon realized he was lost. He reduced altitude and spotted a woman below. He descended a bit more and shouted, "Excuse me, can you help me? I promised a friend I would meet him an hour ago, but I don't know where I am."

The woman below replied, "You're in a hot air balloon hovering approximately 30 feet above the ground. You're between 40 and 41 degrees north latitude and between 59 and 60 degrees west longitude."

"You must be a MEDICAL DOCTOR," said the balloonist. "I am," replied the woman, "How did you know?"

"Well," answered the balloonist, "everything you told me is, technically correct, but I've no idea what to make of your information, and the fact is I'm still lost. Frankly, you've not been much help at all. If anything, you've delayed my trip."

The woman below responded, "You must be a POLITICIAN. And a LAWYER" "I am," replied the balloonist, "but how did you know?"

"Well," said the woman, "you don't know where you are or where you're going. You have risen to where you are due to a large quantity of hot air.

You made a promise which you've no idea how to keep, and you expect people beneath you to solve your problems. The fact is you are in exactly the same position you were in before we met, but now, somehow, it's my fault."

In retrospect, then, increasing demand for medical professionals' time (by expanding insurance coverage) without doing anything to increase the *supply* of medical professionals' time was an insane idea.

Jay did you read the fine print?. "Between August 1 and August 29, 2011, Jackson & Coker conducted a online survey of 1,611 physicians. Jackson had a response rate of 1.44 percent from the 111,792 email invitations distributed."

A 1.44% response rate will give you any result you want, in this case obviously people disaffected with the AMA.

This article in todays WSJ addresses the health care costs and how difficult it is to comparison shop. Anyone who thinks the ACA is not just one part of a large number of changes coming to the medical care profession is fooling themselves. Health care costs are much too high relative to other economic sectors and they are strangling economic competitiveness for the rest of the country.

Revenant said...What I said was that expanding insurance coverage increased demand for medical professionals' time. Not that no uninsured person ever saw a doctor before.

Do you disagree?

There is not enough information to make a sensible decision at this point, despite your certainty on the issue. Clearly the uninsured received considerable medical care before the ACA. It is believed that this care was delivered very inefficiently, in large part through emergency room care which is both costly and very time consuming. If this is true and if the ACA shifts some of this care to more efficient primary care providers then your argument is probably wrong.

I don't see a lack of empathy, rather a lack of understanding of scientists (and engineers.)

A truly fascinating TV show is about Air Disasters. Yes, there is human tragedy involved, but there's also the puzzle as to why it happened, the solution of which will [hopefully] save lives in the future. Thus, were I to say that my favorite air disaster (as just point of reference) is BOAC Flight 781, it's not because I celebrate the deaths or lack empathy, it's because the case is fascinating from an engineering point of view. Moreover, the reasons for this crash led to much greater air safety.

Likewise, in Medicine, a particular case may be fascinating because it was especially difficult to solve and/or because it simply was fascinating. (Man comes into emergency room with an iron rod through his head.

Thought 1: Ick.

Thought 2: Wow, poor man.

Thought 3: How is he still alive! We must find out.

Thought 4: If he stays alive, what effect does this have on his personality?

The beautiful mother laughs at murdering innocent human lives and runs for office. The lawyers (i.e politicians, judges) should stop rationalizing her choice.

Revenant:

Obamacare addresses neither affordability nor availability. It is a revenue program intended to compensate for progressive devaluation of capital and labor, as well as preserve the status quo, while creating a perception of reform. In the best case, it will, as other fiscal policies unbacked by productivity, sponsor corruption. In the worst case, it will force procedural rationing of medical care, and shift the costs throughout the economy, population, and world.

It was probably a Democratic imperative, because they govern in populous, highly subsidized and financed districts, which are especially vulnerable to directed misalignments in fiscal, economic, and social development.

I think their ball of yarns is so convoluted, that no one knows how to unwind it without dashing dreams and the whole ball of hope. I also think that a minority, or perhaps a majority, of Republicans are similarly trapped. In the worst case, there are convergent interests which means there are no competing interests to prevent them from running amuck.

The resolution is not forthcoming. We know the causes. We know the appropriate treatment. We will continue to treat symptoms. Everyone hopes that compensating for the consequences of "good intentions" will be sufficient. Meanwhile, the disease festers.

There is not enough information to make a sensible decision at this point, despite your certainty on the issue. Clearly the uninsured received considerable medical care before the ACA.

Of course most of the uninsured saw doctors before. That's not the issue. The issue is whether more of them access medical care now than before.

There are two possibilities:

1. Yes, more of them see doctors now. Hey, how about that -- increased demand.

2. No, they see doctors either as frequently or less frequently now. In which case ObamaCare has failed at its primary function: expanding access to care.

Like I pointed out before the law even passed, the unavoidable trade-off is between coverage and average cost. The Democrats' promise to reduce costs while expanding coverage was economically insane, and "but we need to do *something*" is no excuse.

Obamacare addresses neither affordability nor availability. It is a revenue program intended to compensate for progressive devaluation of capital and labor, as well as preserve the status quo, while creating a perception of reform.

Rule #1 of politics: never assume the existence of a complicated and carefully implemented conspiracy when "politicians are incompetent" explains the same set of facts.

As for people in the medical field not appreciating gallows humor, that has really not been my experience after 30 years in the field. Physcians can't be stupid like Rep.Steve Stockman or Louie Gohmert, I'm pretty sure any doctor would be better than them.

One was a guy at San Onofre nuclear power plant. He was grinding a chisel when the grinder swallowed it and spit it out into his forehead. Result ? We took it out and he seemed unchanged.

One was a teenager who went with friends to a beach in San Clemente. There was a Mexican gang there and the teens tried to leave quickly. As they were were driving up the road away from the beach, one of the gang had a sharpened paint roller handle and swung it at the kid in the front passenger seat. The kid came in with the paint roller through his head.

Revenant said...Of course most of the uninsured saw doctors before. That's not the issue.

Of course it is the issue. Channeling primary health care for millions of people through emergency rooms is crazy economically. Properly implemented there should be a reduction in health care costs by moving these people to primary care physicians. It should be a win-win, with both lower costs and better overall health care. It is a dynamic problem but you seem to only want to think about it statically.

Inga, Himmelstein and Woolhandler are Harvard full time profs who have been pushing this for more than 20 years. They do not practice and would be unaffected. The docs at the Obamacare press conference, those that were really docs, were new graduates employed by hospitals. I looked them up.

I was at Dartmouth right after Hillarycare was defeated. There were a lot of long faces as they had anticipated that they would be running Hillarycare. These legislative nightmares, like the Massive British flooding or the California drought, have pressure groups, often driven by self interest but sometimes by simple clueless ideology, who support the legal mess.

The British Socialist government after World War II kept Britain in a poverty state while Germany and Japan recovered after losing the war Britain won.

"Channeling primary health care for millions of people through emergency rooms is crazy economically. Properly implemented there should be a reduction in health care costs by moving these people to primary care physicians."

Michael, my family has two physicians as friends . One is a Pediatric Dermatologist, in favor of a National Health Program, the other is a Orthopedic Surgeon, against it. There are plenty of docs who belong to the organization I linked to that are currently practicing.

There is not enough information to make a sensible decision at this point, despite your certainty on the issue. Clearly the uninsured received considerable medical care before the ACA. It is believed that this care was delivered very inefficiently, in large part through emergency room care which is both costly and very time consuming. If this is true and if the ACA shifts some of this care to more efficient primary care providers then your argument is probably wrong."

Those people for the most part were either covered by medicaid or medicaid qualified so the ACA really doesn't change much. And those people will still be going to the ER as they don't want to wait days or weeks for treatment, a situation that has not been or will be improved by the ACA.

So other than illegal immigrants who might be somewhat helped by the ACA and again that is tenuous at best the ACA doesn't improve things for those reliant on medicaid but has demonstrably worsened the situation for the privately insured.

Channeling primary health care for millions of people through emergency rooms is crazy economically.

I know that an emergency room is more expensive for basic treatment. ( The specific example I heard was a visit for a sprained wrist was 3 times more expensive at an emergency room than at a doctor's office. ) Does anyone know why it costs more at an emergency room?

It seems it should cost less. They've got efficiency of scale for medicine, supplies, computer systems, etc. And having a large number of minor injuries should improve their resource utilization. They need to be staffed and equipped to handle X number of critial, can't wait patients at a time. But most of the time they have half that number or less. If they have non-critical patients too then they can better utilize the resources during the lulls.

Channeling primary health care for millions of people through emergency rooms is crazy economically. Properly implemented there should be a reduction in health care costs by moving these people to primary care physicians.

You know absolutely nothing, not 1 single thing, about this topic.

Why you want to just post these bromides, other than to troll, isn't clear.

A large part of the problem is the 24 hour nature of ERs. When I ran a trauma center, we set up an after hours clinic nearby to keep the "worried well" out of the ER. Later the pediatricians kept it going as "Kids Doc" which they staffed as an after hours clinic so they could share the burden of after hours care.

"Channeling primary health care for millions of people through emergency rooms is crazy economically. Properly implemented there should be a reduction in health care costs by moving these people to primary care physicians."

ARM, You accomplished something. You and Inga got me to log onto the physician only website, called Sermo, that I hadn't looked at in years. A quick perusal of the politics segment tells me that physicians, and Sermo has 200,000 subscribers all MD or DO, are not happy with Obama or Obamacare. I'll look to see if they surveyed the members.

Michael- thanks for the response. But why would the 24 hour nature of the ER raise costs so much? Are doctors being paid a huge shift premium for the off hours? Even if the doctors were getting paid double that should result in significantly less than a doubling of the patient bill.

Note I'm not accusing anyone of overcharging, or anything like that. I'm just trying to understand

I suspect a good bit of the high price is due to cost shifting. Because the ER treats people who could not pay, they were then charging everyone else more to cover their losses. Also, the hospital must be equipped with lots of expensive equipment, in case it is needed. The cost for those are spread across everyone, even those who don't use it.

However, if the reason the ER is so expensive for routine treatment is due to cost-sharing, then shifting usage to primary care physicians doesn't help. The costs are still there, even if they are no longer shifted. The primary care visit would cost less, but those people who actually need the ER would have to pay more, because the capital expenses must be paid for by fewer patients.

I am not sure why the leftists here would think that physicians would love ObamaCare. It greatly increases their paperwork, in many cases pushing them into larger and larger practices, reduces their pay, as well as their freedom to practice medicine. And, now, they are having to dump long time patients whose new policies don't include the doctors - often in the middle of treatment. The ones who work for large companies, maybe. Those who work for the government already, sure. But all the physicians in small to medium practices? Highly unlikely.

First, you have to understand now bad hospital billing is. What you see if a "retail" charge that is intended for the insurance company, which then pays a negotiated percentage of that charge. The negotiated part may be a small fraction. Look at a Medicare EOB sometime. I go to a pain doc sometimes and he charges $120 for an office visit. Medicare pays him $11. Most primary care docs now live on the co-pays.

The ER bill, like most hospital bills, is not intended to be actually paid like you would pay an electric bill.

The illegals who fill ERs never pay anything. The Medicaid patients who fill most of the rest, don't pay and Medicaid pays a small fraction. When I used to see Medicaid (MediCal in California) patients 30 years ago, most of them were coming for varicose vein injections (I was a vascular surgeon) and MediCal paid me six dollars a visit for the injection. That didn't pay my costs so I quit seeing MediCal.

Primary care docs who are forced to see MediCal because of where they practice, often pad bills to get some decent amount of payment. This is actually fraud and once in a while there is a scandal.

When we admitted trauma cases that were MediCal, there was usually big ticket items and the payment was based on that. Most of our traumas were actually insured because of where we were (South Orange County) and mod were auto accidents. If we had been in an inner city location, we would not have been enthusiastic about a trauma center and most are hospital based and the docs are paid by the hospitals.

The Kids Doc, in contrast, is run by private pediatricians and is in an office building, not the hospital. A lot of their patients have insurance or it would never work.

Some Urgent Care offices are on the same principle. It's not a hospital with all their fixed costs. Hospitals, of course, hate this and one reason the AHA signed on to Obamacare was to use it to shut out Urgent Care and doctor owned facilities like surgery centers and specialty hospitals. It will be interesting to see how it plays out.

My friend who was over last night for dinner told me they are laying of staff in spite of being very busy. This will drive surgeons away who want good service in scheduling surgery and getting things done instead of waiting around.

Obamacare may drive more doctors away from hospitals and add to the trend to cash practice. The doctor owned hospitals, excluded from Obamacare, may turn to the cash model.

According to the Patient Protection and Affordable Care Act, no physician-owned hospitals may start or current ones expand.

Inga, the guy who wrote that column thinks doctors would be in charge if we went to Medicare for all. He is a dreamer or not serious.

You might read my own ideas on reform written before Obama ran for president. I favor a French style system. I doubt you will read any of it because I think you are a lefty partisan and uninterested in real ideas.

Taking time out from defending dems from calling women "cunts", Inga pops up to reflexively leave out the most salient aspects of Reagans career:

1) Head of the Screen Actors Guild during a very interesting time2) 8 years as the spokesperson for GE theatre (wherein he visited approximately 135 GE research and manufacturing facilities and met over a quarter-million people.)2a) These would be manufacturing/factory people, union people, non-union people. The heart of the US productive sector in addition to the leaders of those businesses and industry3) Governor for 8 years of the largest state in the union.

A large proportion of patients in EDs do not have insurance, aphenomenon attributed to the 1986 Emergency Medical Treatment and Labor Act.

EMTALA requires hospitals that participate in Medicare to:1. Give a medical screening exam to any patient who presents to a dedicated ED or requests treatment for an emergency medical condition while on the hospital campus;2. Stabilize the condition if feasible at the facility; and3. Transfer the patient to another appropriate medical facility if the patient cannot be stabilized at that hospital.

Again, thanks for the info. It seems to confirm my suspicion that the high costs are really cost-shifting, and therefore shifting where the patients are seen will make little difference to the total amount of healthcare spending.

That is assuming that the ACA shifts usage away from the ERs. MassCare had the opposite experience.

Michael K, I've already read it, you've directed me to it before. I actually agreed with you at some point and then you proceeded to ignore what I said lambasted me for agreeing with you on the French model! Then I decided you were not to be taken seriously, or perhaps you were simply being contrary. I really don't know and I'm tired to tryin to figure out where you are coming from on an given day.

As a result, many hospitalssubsidize specialists for theiron-call duties. This compensation may take the form of stipends to specialists for taking call, guaranteed pay for services rendered to uninsured patients, or other fee arrangements.

Many EDs face difficulties getting paid for services. A 2003 study of two HMOs in California found that one of the categories of most frequent denialwas emergency care (17% were denied).

"The ED differs from many other hospital specialties in that the ED has relatively high fixed costs, but may exhibit relativelysmall and potentially decreasing marginal costs. The high fixed costs are associated with 24-hour staffing and the equipment required to accommodate all patient types and a wide range of diagnoses and treatments.

...The marginal costs are the variable costs associated with treating an additional patient.

...more recent research using a large database of hospitals in California found that the marginal cost of an ED visit might actually be quite high, on the order of $300 per visit...which reflect many of the changes that have affected ED financing over the past decade, including greater managed care penetration, increased price competition, and the cost of compliance with EMTALA regulations.

This has led to difficulty in evaluating the fiscal performance of the ED, even if the ED’s presence in the hospital ultimately improves its financial performance. When one considers the additional challenges ofoperating a hospital ED —the inability to prescreen patients, the large amount of uncompensated care, declining reimbursements, ahigh rate of denials for payment, and the proportion of high-risk patients and associatedmalpractice risk— it is easy to understand why the ED might be perceived as a financial liability for the hospital."

Are there too many doctors in Congress?Asks the Law Prof, knowing that approximately 40-50% of Congresscritters have law degrees. Talk about special interest pleading...

More lawyers in Congress mean more laws that only lawyers can understand (remember that Congressman who professed to be amazed someone expected him to actually read the Obamacare bill?). That means more pay for lawyers--and more deadweight loss for the rest of the economy. Screw that.

ARM, You accomplished something. You and Inga got me to log onto the physician only website, called Sermo, that I hadn't looked at in years. A quick perusal of the politics segment tells me that physicians, and Sermo has 200,000 subscribers all MD or DO, are not happy with Obama or Obamacare.

Ignorance is Bliss said...Does anyone know why it costs more at an emergency room?

There is endless stuff on this but I can give a personal anecdote. Not that long ago I went to the emergency room because I was really in bad shape after a significant surgery. I knew exactly what was wrong and what I needed. It was a weekend and the surgeon was out of town so I didn't have a lot of options. I spent several hours being given unnecessary procedure after unnecessary procedure. I explained patiently at first and then with increasing frustration that this was all a waste of time. They ignored me. I ended up walking out and making a formal complaint to the hospital. Emergency rooms have no knowledge of the health status or sophistication of the patient and have to use a one size fits all approach that is very wasteful and expensive. To give balance, it is a very difficult environment to provide health care, the typical person can have a very challenging problems and also be clueless. Nonetheless, having wasted hundreds if not thousands of dollars I ended up receiving exactly zero useful health care.

"I knew exactly what was wrong and what I needed. It was a weekend and the surgeon was out of town so I didn't have a lot of options."

One option you had was to call the on-call physician for your surgeon. No hospital I have ever been associated with will allow a physician membership on the staff without providing an on-call alternative when he/she is not available.

Holy Crap , Ann. What is it with LAWYERS??? That is one of the problems with our laws and Congress today -- too many lawyers in Congress. How about electing someone who has actually WORKED for a living.??

The NHS is notorious for ER waiting times. The NHS then institutes a "four hour rule" that required patients to be seen within 4 hour of arrival. This seems to be a challenge but it was neatly met by making the ambulance wait in the parking lot until the ER was less crowded.

An investigation by The Sunday Telegraph shows that the number of patients forced to wait at least two hours parked outside A&E has risen by two thirds in just one year.Official figures from eight of England’s ten ambulance trusts show that in 3,424 patients waited more than two hours before “handover” to hospital staff during 2012/13 – compared with 2,061 such patients the year before.

Gee, I guess the talk about how exepenive and inefficient it is to use emergency rooms for non-emergency care might be a bit misplaced in an argument about how the PPACA will save money and increase efficiency, then.